A health plan may agree to at least partially pay for one or more healthcare services obtained by a covered member. For example, the health plan may include a health insurance plan, a health maintenance organization plan, and/or other type of plan that imposes at least some responsibility to pay for healthcare services obtained by a covered member. The health plan may include public and/or private plans provided by public or private entities. For example, a health plan may include a government health plan (e.g., a U.S. Federal provider such as Medicare or a local government health plan) and/or a private provider of a private health plan.
A member may include one or more individuals or entities covered by a health plan. A given member may be covered by two or more health plans. In such a case, the two or more health plans may individually have primary, secondary, and/or other responsibility to pay for healthcare services received by the given member. The different levels of responsibility can cause problems.
For example, members may conventionally provide a healthcare service provider such as a physician, dentist, hospitals, labs, DME vendors, etc., with health plan information such as a health plan identification that identifies the health plan. Oftentimes, the provided information is incorrect or incomplete, causing the healthcare service provider to incorrectly request payment from a secondary health plan rather than a primary health plan that should have been billed or to request payment from a single health plan when a secondary health plan should also share in the payment. Even when payment requests are submitted to the proper health plan, correctly apportioning the payment among the primary and secondary health plans can be problematic. Oftentimes one health plan is unaware that the member is also covered by another health plan and the details of the other health plan are unknown.
When other health plans are identified, apportioning payment responsibility is oftentimes performed incorrectly because appropriate primacy information that indicates payment responsibilities is unavailable, unknown, or is misinterpreted. Such apportionment can also be performed after one of the health plans has already paid for the healthcare service, causing further inefficiencies of conventional systems and methods. These and other inefficiencies result in higher costs for several parties involved, from healthcare service providers to health plans.